- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.25 / $187.94 / $228.30
| Professional | | $147.25 | $187.94 | $228.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.94 / $199.22 / $292.22
| Facility | | $187.94 | $199.22 | $292.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,900.00
| Professional | | $30.00 | $30.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.73 / $3,612.83 / $4,302.32
| Facility | | $2,559.73 | $3,612.83 | $4,302.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.20 / $273.20 / $375.26
| Professional | | $259.20 | $273.20 | $375.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.91 / $241.94 / $413.43
| Professional | | $175.91 | $241.94 | $413.43 |